Background to this inspection
Updated
31 August 2018
Church Street Surgery is the provider of the practice which is located at 57 Church Street, Hunslet, Leeds LS10 2PE, in the south east area of Leeds. The practice premises are owned by the GP partners. There is a small car park for staff and patients and nearby on street parking.
The National General Practice Profile shows the level of deprivation within the practice demographics being rated as one. (This is based on a scale of one to ten, with one representing the highest level of deprivation and ten the lowest.) The patient population are mainly white British, with 88% of patients being under the age of 65 years.
The provider is contracted to provide Primary Medical Services (PMS) to a registered population of approximately 1,971 patients. The current provider has seen an increase of over 330 new patients since June 2017.
The provider is registered with the Care Quality Commission to provide the following regulated activities: diagnostic and screening procedures; treatment of disease, disorder or injury and maternity and midwifery services
The practice clinical team is made up of two GP partners (one male, one female) and one practice nurse. They are supported by a practice manager and a small team of administration and reception staff. The practice has access to a locality healthcare assistant.
Opening times for Church Street Surgery are 8am to 6pm Monday to Friday, with the exception of Wednesday when they are open from 7am.
Routine and urgent appointments are available, along with telephone consultations as appropriate. When the practice is closed out-of-hours serviced are provided by Local Care Direct, which can be accessed by calling the NHS 111 service.
We saw that the ratings from the previous inspection were displayed in the practice. The practice does not have their own website.
Updated
31 August 2018
This practice is rated as Good overall.
Dr Shahzad Hussain has been registered as an individual with the Care Quality Commission since December 2016. (An inspection was undertaken in June 2017 when the practice was rated as good overall.) However, since February 2018 the registration was amended to become a partnership between Dr Shahzad Hussain and Dr Nazima Hussain.
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
As part of our inspection programme, we carried out an announced comprehensive inspection at Church Street Surgery on 14 August 2018.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
- The practice could evidence safe and effective prescribing in line with local and national guidance.
- There were comprehensive systems in place to support safe and effective management of the practice.
- We saw that an emergency telephone protocol had been developed, which included symptoms to be aware of relating to sepsis and how concerns should be responded to. The protocol had been shared with other practices locally.
- There was a focus on continuous learning and improvement. The practice had developed a diabetic foot screening protocol which had been presented locally with a view to being adopted by other practices.
- The practice regularly reviewed demand and capacity regarding the appointment system. Patients reported that they were able to access care when they needed it and were positive about the practice.
- The practice engaged with other local providers of health and social care to respond to patients’ needs. For example, the development of a ‘dressings hub’ to support patients who required urgent dressings post discharge.
The area where the provider should make an improvement is:
- Put measures in place to ensure the plug for the vaccine refrigerator could not be accidently removed or turned off.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence table for further information.